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Checks on specific services

Medical care (including older people’s care)

Our rating of this service went down. We rated it as requires improvement because:

Areas used for escalation at times of high operational pressures where not always suitable and safe for patients and staff overnight.

Risk assessments for venous thromboembolism (VTE) were not always completed in a timely manner. This was not in accordance with national guidance.

The sepsis protocol and care bundle was not used consistently across inpatient wards. Not all staff could remember if they had received training on sepsis. However, staff were aware of signs and symptoms of sepsis.

Intravenous fluids given to patients receiving haemodialysis were not always prescribed before they were administered. Patients’ blood pressure may drop during haemodialysis for which intravenous fluids are given. These fluids were given via the dialysis machine and not always prescribed and given in accordance with national guidance.

Nursing staffing levels did not always meet the acuity and dependency of patients on inpatient wards. The medical care group has seen an 8% increase in patients admitted to hospital but the planned staffing levels had not been increased in line with the increased activity.

Medical staff did not always meet required staffing levels. There were vacancies at all levels including consultant vacancies.

Training compliance for medical staff in mental capacity act and deprivation of safeguards liberty was 59.5% against a trust target of 95%. Mental capacity assessment forms were not always correctly completed, which meant mental capacity assessments were not always fully completed.

Deprivation of liberty safeguards (DoLS) were not always completed. This was not in accordance with the Cheshire West Supreme Ruling (2015).

Some clinical guidelines on the trust intranet had exceeded their review date, which meant staff could not be assured they reflected current and most up-to-date guidance.

There were not enough medical beds to meet the demand of medical admissions to the trust. The systems to promote patient flow were effective, but the increasing demand outweighed the capacity available within the trust.

Processes to ensure discharge from hospital for those patients medically fit to leave were not always effective. There was a high number of patients medically fit for discharge who were unable to leave hospital.

There was a high number of patients who were remained in hospital for more than seven days. These patients are known as ‘stranded patients’. These patients occupied between 41% - 44% of the total number of beds in the hospital at the time of our inspection.

There was not sufficient scrutiny and challenge of mortality figures to provide assurance of adequate overview of mortality within the medical care group.

Not all staff felt able to raise concerns without the fear of retribution.

However:

The medical care group had a good safety record. Staff were aware of, and adhered to infection prevention and control measures.

Leaders and ward managers had the skills, knowledge, experience and integrity to lead teams effectively. The trust had recently introduced a leadership and talent strategy.

Most staff felt supported, respected and valued. All ward managers and matrons stated they were proud of their staff, their hard work and commitment to provide high quality care to patients.

There were processes and systems of accountability to support the delivery of good quality and sustainable services. There was a formal governance structure within the medical care group, which helped to ensure effective governance.

There were arrangements for identifying and managing risks. We spoke with ward/department managers and leaders and found that personal concerns about risks were aligned with those risks added to the risk register.

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Services for children & young people

Good

Updated 25 November 2016

We have rated the safety of services for children and young people as good because:

There were processes to report incidents with details of full investigations having been completed where appropriate. Learning points were shared with staff. Staff were confident in reporting incidents and always received feedback on progress of the investigations. Staff described being open and honest with patients and their relatives when anything went wrong.

Standards of hygiene were monitored by staff with specific roles in infection control and areas we visited were visibly clean. Where incidences of infection were found, appropriate action was taken to control it.

Medicine storage, prescribing and administration was managed to ensure children and young people received the correct medicines at the correct time. Pharmacy staff worked with staff on the paediatric wards to ensure staff were aware of safe protocols and any errors were highlighted as soon as possible.

Children’s weights were available in most cases for staff to prescribe appropriately.

Safety audits were viewed by the management team to identify areas where practice needed to be improved with actions for monitoring progress.

Records were kept securely to maintain confidentiality for the patient but were available for staff to view when required.

Staff were aware of safeguarding processes and knew how and when to ask for supervision or support.

Risks to patient safety were identified and reported to senior managers and actions were taken where possible. The last inspection had highlighted concerns over observations of oncology patients following cancer treatment procedures. Delivery of care to these patients had been reorganised and observations were now happening. Risks for children and young people who may harm themselves had been assessed and reduced by adapting the facilities and environment. For example, a room had been identified that was safe for young people to stay in and calm down and ligature risks had been removed. This room also protected children from witnessing disturbing behaviour.

Emergency equipment appropriate for all ages of children and young people was available for use.

Numbers of appropriately qualified staff on the ward areas we visited met the levels set out in national guidance. Managers achieved this by using staff flexibly across the paediatric areas. Staffing levels were monitored using a tool to assess how many staff were required to provide care for the number of patients and the level of care they needed.

Medical staff ensured there were enough senior staff to provide expertise and advice for paediatric care. Medical staff were also providing specialist safeguarding clinics five days a week.

The community paediatrics team provided a safe multidisciplinary and multiagency service for children and young people who required assessment, support and intervention to ensure their wellbeing and development.

Services were provided in a child friendly environment by a highly skilled workforce at the Child Development Centre and by the children’s community nursing service. When clinically required, a visit was carried out at a child’s home, nursery, school or other locality setting. This minimised the need for multiple appointments, and duplication of history-taking and documentation.

Following the last inspection there were concerns with regard to the insufficient number of child assessments and care plans that had been completed in the children’s community nursing team. During this follow up inspection we found the issues had been resolved and patient records were maintained and monitored.

However:

Safeguarding update training for staff was at 91% which was not compliant with the 100% trust target. There were plans to enable staff to attend this training.

Mandatory training for staff in one subject area was 80% which was below the trust target level of 100% compliance, although staff we spoke with were aware of when and how to update their training.

Two pieces of equipment we saw indicated they had not been serviced within recommended timescales.

In one area we visited there was an out of date Children’s British National Formulary alongside the current version creating a risk of staff using outdated prescribing information.

Patient details were displayed on an electronic board where visitors could view it which could compromise a child’s privacy.

Children and young people needing more intensive support from child and adolescent mental health services were cared for on the ward until a bed became available.

An oxygen cylinder for emergency use in a community setting was not easily portable.

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Critical care

We have rated the responsiveness of the critical care service as good because:

The services were planned and delivered to meet people’s needs and co-existing conditions. The services met with local clinical commissioning groups to plan, evolve and improve their services.

There were arrangements for relatives to stay close to the hospital in purpose-provided accommodation. They had access to facilities, including food and drink, and extensive information in bedside folders about all services within the hospital and the wider community.

In accordance with specialist guidance, a consultant reviewed patients in both the critical care units within 12 hours of their admission.

A productive and efficient working relationship had been established between the general/neurosurgical critical care team and the bed management team. This had brought the issues affecting critical care more to the fore and improved access and flow for patients. Cardiac services had been reconfigured to improve delays, access and flow.

The general/neurosurgical unit had made good progress to reducing the number of patients discharged at night. This was continuing to improve.

There had been significant progress in reducing the delays in discharging patients from the general/neurosurgical unit. The results showed the unit was now below (better than) the average for similar units for delayed discharges.

There had been productive consultations between medical teams, and improvements and adaptations to operating theatre lists to help with access and flow in the general/neurosurgical unit. This had led to new efficiencies and reduced the number of operations cancelled due to lack of a critical care bed. There had also been work undertaken to adapt clinical pathways in cardiac services, and find alternatives to admission to critical care.

There were almost no patients transferred to another hospital due to lack of a critical care bed. There had been a high level of flexibility and response from the critical care teams to enable almost all patients to be admitted to the units when they needed urgent and emergency care.

The individual needs of patients were taken into account and patients were well supported. Care was tailored to the needs of patients, and their preferences and circumstances were understood and acknowledged.

Complaints were listened and responded to, and used to improve patient care and support.

Patients and their relatives were included in feedback and investigations of complaints, and told when practice had changed because of their input.

However:

The critical care services had yet to establish the dedicated psychology service, although had made good progress with commissioners, and already obtained partial funding for the new services.

The cardiac critical care unit had yet to contribute to the Intensive Care National Audit and Research Centre in order to obtain and learn from valuable benchmarking against other similar units. This had been recognised, and work towards producing data was underway.

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End of life care

Good

Updated 25 November 2016

We have rated the service as good for effective because:

Patient needs were assessed and treated in line with evidenced based guidance. Pain management and the management of nutrition and hydration was assessed, managed and recorded to ensure patients at the end of life were comfortable.

Following the previous inspection a local quality improvements in environment project had been undertaken. Areas of improvement were planned, for example single rooms available for privacy for patients at the end of life. The timescale for completion was two years.

End of life outcomes were monitored against national standards. Outcomes from previous audits had been used to make changes to patients care.

Ward staff had sufficient training and the ongoing support and help from the Specialist Palliative care Team to deliver effective care and treatment. Access to the specialist palliative care team had increased to seven days a week.

The multi-disciplinary working between the Specialist Palliative Care Team and the wider hospital and local community were outstanding. The integrated working supported a continuity of care and the

prevention of avoidable admissions.

Improvements were seen in the completion of the Treatment Escalation Plans (TEP) but auditing of improvements was not yet fully completed. The management of Deprivation of Liberty safeguards ensured the safety of patients.

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Maternity and gynaecology

The delivery suite was consultant led and able to support women with high risk pregnancies or complex health. Patients assessed as having low risks were appropriately supported by midwives.

Staff were knowledgeable about incidents and learning from these was demonstrated.

Patients had risk assessments completed and reviewed regularly.

There were established and thorough safeguarding systems in place to protect vulnerable adults and children.

The delivery suite had been partially refurbished and some faulty equipment had been replaced, which enabled more effective cleaning.

Records and medicines were safely stored and equipment had been regularly checked.

Discharge processes had not been reviewed but this was promptly amended during out inspection.

However:

The maternity services should have clearer processes in place in order to be able to identify the percentage of staff who were compliant with mandatory and other safety training. Related to this, we found staff training was urgently required for emergency procedures using the birthing pool.

There were no plans in place to complete the refurbishments on the delivery suite.

The cleaning policy and procedure for the birth pool required reviewing.

People’s care and treatment was planned delivered and monitored in line with current evidence-based guidance.

People had comprehensive assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.

Staff spoke of good teamwork and enjoyed their work. Managers and senior leaders were proud of the workforce. Staff at all levels were clear about their roles and understood for what they were accountable.

The surgical care group leads and other levels of governance in the organisation functioned effectively and interacted with each other appropriately. Leaders were knowledgeable about issues and priorities for the quality and sustainability of their services.

People had comprehensive assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.

However:

Staffing levels did not always meet the need of the patients to ensure safe care and treatment.

People could not always access the service when they needed it. The division was not achieving targets for patients receiving treatment within the targeted timeframe, this included cancer waiting times.

During times of escalation and bed pressures, facilities and premises used were not always appropriate for surgical patients and patient’s dignity and respect could not always be maintained.

Cancelled Operations as a percentage of elective admissions were consistently higher than the England average. Theatre utilisation was worse than the national average.

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Urgent and emergency services

Requires improvement

Updated 15 August 2018

The department was not designed to safely manage the numbers of patients that regularly attended. There was frequent crowding and the use of the corridor area prevented fast and easy movement through the department. There was insufficient equipment available to monitor the number of patients in the department, visibility of patients in the corridor was poor, and there was a risk to deteriorating patients being missed as a result.

The resuscitation area was too small to enable the required equipment and staff to easily work, especially in the event of major trauma, and to accommodate the numbers of patients requiring resuscitation facilities. The four-bedded resuscitation area was frequently full, and patients were moved out of resuscitation before staff felt this was clinically appropriate because the space was needed for other patients who were more unwell.

The paediatric department doors were not secured, meaning unauthorised persons could gain access or children could leave without being challenged. There were also unprotected electrical sockets within reach of children.

While staff understood their responsibilities to report incidents, there was often limited time to do so and longstanding issues were often not reported because staff didn’t believe action would be taken.

Patients waiting for X-rays were unattended, unobserved, and left with no means of calling for help. We found a patient with dementia in a distressed state and trying to pull out a needle in the back of their hand, which a family member of another patient had to stop.

Staffing in the department was not sufficient to safely manage the numbers of patients at all times. This was particularly evident during the regular periods of crowding.

Receptionists were not trained to recognise seriously unwell patients and were not provided with any guidance to help them recognise ‘red flag’ signs and symptoms.

The department was not using an early warning score system for adult patients and observations were not being recorded regularly. Staff used their discretion to determine how often observations should be completed, but we found significant gaps in the records we reviewed.

Patients suspected of having sepsis were not always treated with antibiotics within 60 minutes.

Pain relief in majors was not always provided in a timely way, and pain scoring was not consistently completed in observation charts.

There was mixed performance for treating patients against national standards, for example in the case of asthma and sepsis some standards were worse when compared nationally, while other standards such as vital signs in children and procedural sedation were either better or in line with national standards.

Yearly appraisals were not completed in line with the trust’s target for any of the staffing groups working in the emergency department.

It was not possible to easily recognise the roles of each team member during a trauma call because staff did not always wear the correct tabards.

Capacity assessments and consent was not always clearly recorded in patients’ notes.

There were times when patients’ privacy and dignity was not maintained, usually due to the high workload staff were managing and the design of the department.

The privacy of patients arriving by ambulance was not maintained because there was nowhere private for the handover of confidential information to take place.

There was no protection from the weather for patients arriving by ambulance or being dropped off by car outside the department.

Patients with mental health conditions were required to wait with other patients in the busy department because there were not any dedicated facilities, apart from an assessment room.

Flow through the department was slow and patients often waited long periods of time before they were admitted, transferred or discharged. The department had failed to meet the four-hour standard during the previous 12 months and was consistently performing below the national average.

Escalation processes in response to high demand and crowding were slow to provide additional support and often had little impact.

Team meeting minutes generally lacked detail and only captured brief notes about the areas of discussion. These meetings did not have action trackers so there was no central oversight of progress against required actions.

Control measures for several risks did not appear to be having the intended outcome and as a result these risks remained a significant concern.

Confidential patient information was not always given the care it required. For example, we found a list of patient names and hospital numbers alongside their pregnancy test results in an unattended, unobserved room in a public corridor.

There were limited means of public engagement and feedback from the public was not actively sought.

However:

Although mandatory training compliance was below the trust’s target of 95%, most staff were up-to-date with mandatory training.

Staff understood their safeguarding responsibilities and most were up-to-date with the appropriate level of safeguarding training. There were clear processes for staff to follow and staff felt comfortable using these.

Despite being cluttered in some areas due to a lack of space, the department mostly appeared to be tidy and was visibly clean. Staff generally followed good infection prevention and control processes, although there were several occasions where patients in the corridor were treated by staff who had not cleaned their hands.

Patients with a mental health condition were referred promptly following triage to the psychiatric liaison service, provided by a local community provider.

The department had a variety of risk assessments available for patients, including for falls, pressure ulcers, and the need for bed rails. We found these were completed appropriately in most patient records.

Guidelines were in place to support staff to provide effective treatment, and these were up-to-date with national guidance and standards and regularly reviewed and audited.

Patients in minors had their pain assessed at triage and were offered appropriate pain relief in a timely manner.

Staff were competent to carry out their roles and were provided with training opportunities to develop their skills, including simulated scenarios.

There was excellent multidisciplinary team working both within the department and with teams outside the department, including external partners.

Despite challenges caused by the environment, demand and crowding, staff did their best to provide compassionate care to all patients.

The department consistently scored above the national average in the NHS Friends and Family Test.

Patients and their relatives were provided with appropriate emotional support where required, and staff took the time to ensure this took place.

Most patients felt they were involved in decisions about their care, and felt staff listened to them during discussions about their care.

Staff could support the needs of most patients, through access to appropriate specialist teams and services. These included, for example, learning disabilities, dementia, frailty and translation services.

Work was ongoing to reduce attendances at the emergency department by using the acute assessment unit for appropriately referred patients.

There was a generally supportive and respectful culture, although there were some groups of staff who felt this was not the case.

Staff wellbeing had a high priority and a wellbeing committee had been established to deliver projects to improve staff wellbeing, including a week-long wellbeing festival.

Governance processes had been strengthened. Governance meetings were well-attended and included representatives from management, medical and nursing staff groups. Minutes of governance meetings were well-maintained and actions were recorded and tracked.

Risks in the department were well-understood and documented. The risk register aligned with the concerns staff and leaders told us about, and was regularly reviewed and updated.

Staff responded quickly and efficiently in response to a fire alarm in the department requiring a full evacuation. It was clear staff had received appropriate training to manage such a risk.

There were effective arrangements to ensure the information used to monitor, manage and report on quality and performance was accurate, valid, reliable, timely and relevant.

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Medical care (including older people’s care)

Updated 5 March 2019

This was a focused follow-up inspection. Therefore, we did not rate this service. There was progress in addressing the concerns in the warning notice, although some areas had not been well considered or implemented quickly enough for medicine and pharmacy services.

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Maternity

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

Not all staff had completed mandatory training including emergency procedures, which is designed to give staff the knowledge and skills to keep people safe.

Throughout maternity services, we found equipment which had not been cleaned, checked or maintained to ensure it was safe to use; this included equipment used in an emergency.

We could not be assured that medicines were managed properly to ensure secure storage, or integrity of the product.

Patient Group Directions (PGD’s) were not managed in accordance with National Institute for Health and Care Excellence (NICE) Medicine Practice Guideline for PGD’s issued in August 2013.

Records were not always stored securely or filed appropriately to produce a complete account of a woman’s maternity care.

Risk management processes did not capture threats to the service and were not always measured appropriately. This resulted in a lack of oversight for those responsible for the performance of the service.

Governance processes, involving the timely review of clinical documents and their control, were not robust enough to ensure the latest evidence based practice was integrated into policies and procedures.

New roles and practices, for example obstetric nurses were not assessed or evaluated to understand the potential risks to patient safety and how these may be managed.

We were not assured midwives working in the High Dependency Unit had been assessed as competent in the skills required to care for a seriously unwell woman.

However:

There was evidence of exemplar multidisciplinary relationships between all staff groups across the maternity service. Teams worked effectively together to create a supportive and open culture which included colleagues employed by other services. All staff told us they felt valued and respected.

Patient outcomes were monitored to identify areas for improvement.

Staff at all levels had a caring and compassionate approach to patients who spoke highly of the care they received.

The trust planned services to meet the needs of the population it served. They were in the process of re-evaluating provision to see how this could be improved.

Women had access to the maternity services 24 hours a day, seven days a week.

Mental health and wellbeing was continuously assessed and support was accessible when needed.

Staff offered sensitive and compassionate support to bereaved women and their families.

The medical rota provided onsite obstetricians 24 hours a day and avoided the use of temporary staffing.

We found examples of continuous improvement for effective discharge and bereavement support.

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Outpatients

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

There were well established links with the onsite mental health liaison team to help protect vulnerable patients.

Risks to patients were assessed monitored and managed in line with national legislation and guidance.

Most environments and equipment in the outpatient department kept people safe from harm and were visibly clean.

Techniques used to ensure cleanliness were in line with national quality standards.

Medicines were managed in line with national guidance and legal requirements, and we saw improvements made as a result of audits.

There was a good incident reporting culture and openness and transparency was encouraged.

Staff understood their responsibilities to raise concerns and report incidents, and we saw evidence of action taken when as a result.

Patients’ care and treatment was planned and delivered in line with current evidence based guidance, and audits were carried out to ensure practice was monitored.

Staff were suitably qualified and had the skills to carry out their roles effectively, and the learning needs of staff were identified through appraisals.

When people received care from a range of different staff, teams or services, this was coordinated well, ensuring all relevant teams were involved.

Staff understood how important it was to work collaboratively to meet the needs of the patient.

Patients’ privacy and dignity was respected in all aspects of care throughout the outpatient department.

Staff took the time to interact with patients and their relatives or carers, and were kind and helpful.

Staff understood the impact of the treatment/diagnosis on patients’ emotional wellbeing and actively supported patients.

Staff could signpost patients to relevant support services and groups.

Staff communicated with patients so they understood the treatment they received and what was going to happen next.

Services used a proactive and innovative approach to how clinic utilisation and capacity was to be planned in the future.

The needs of different people were considered with the reasonable adjustments made for patients living with dementia and learning disabilities.

The environment was equipped to manage the specific needs of patients and training had been rolled out to all staff.

Complaints were managed well within the outpatient service and most people we spoke with knew how to make a complaint. Lessons were learnt from complaints and were discussed within governance meetings and with staff.

Patients could make appointments through a system which offered choice and convenience.

There was a clear strategy for outpatients with defined objectives that were regularly reviewed and relevant to the current and future challenges services faced.

There were good governance structures, processes and systems throughout outpatient departments to ensure accountability, the management of risk, the management of performance, and regular review to gain oversight of how the services were performing.

The leadership team in the outpatient department were supportive of their staff and had the knowledge, skills, experience, and time to manage their services.

Leadership had good oversight of the quality of care. We saw the positive impact audits had on individual outpatient areas.

Staff and patients continued to be engaged in how care was delivered, and felt they were active contributors. Patients had various forums in which they could raise concerns and bring ideas.

Leaders and staff strived for continuous learning, improvement and innovation.

However:

Not all medical staff in outpatients were up to date with their required mandatory training, including safeguarding training.

The environment and space within some clinics and their waiting areas remained an issue and some areas did not have sufficient seating.

We found unattended records in an unlocked room in the Royal Eye Infirmary.

Most services were not available seven days a week, mostly due to staffing and capacity issues, however this was a key target of the newly developed outpatient strategy.

There were long waiting times and delays for some outpatient appointments. Although improvements were being made, some patients were not able to access services for assessment, diagnosis or treatment when they needed to.

The outpatient department was not meeting the national target for cancer waiting times for two-week-wait urgent patients or for 62-day pathway patients, although improvement plans had been developed.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.